Systems, devices, and methods for securing tissue

ABSTRACT

Systems, devices, and methods are provided for securing soft tissue to bone, for securing one or more objects using a surgical filament, and for drawing two or more tissues together so they can be secured in a desired location. One exemplary embodiment of a surgical repair construct that is configured to atraumatically pass through soft tissue to secure tissue in a knotless manner includes a snare linkage, a collapsible loop, and a flexible suture pin. The snare linkage can include a collapsible snare for receiving the collapsible loop, and in use the snare can be collapsed around the collapsible loop and advanced distally towards the bone until the snare is proximate to the tissue, while the collapsible loop can be collapsed distally towards the bone to bring the tissue into proximity with the bone. Other exemplary systems, devices, and methods for use with soft tissue repair are also provided.

CROSS REFERENCE TO RELATED APPLICATIONS

The present application claims priority to and is a divisional of U.S.patent application Ser. No. 13/465,288, filed May 7, 2012, and entitled“SYSTEMS, DEVICES, AND METHODS FOR SECURING TISSUE,” which is herebyincorporated by reference in its entirety.

FIELD

The present disclosure relates to systems, devices, and methods forsecuring soft tissue to bone, and more particularly relates to securingsoft tissue while minimizing or eliminating the tying of knots totension and secure the tissue. The systems, devices, and methodsprovided herein can also be used to secure one or more objects, such asa bone fragment or tissue, and to draw two or more tissues together sothey can be secured in a desired location.

BACKGROUND

A common injury, especially among athletes and people of advancing age,is the complete or partial detachment of tendons, ligaments, or othersoft tissues from bone. Tissue detachment may occur during a fall, byoverexertion, or for a variety of other reasons. Surgical interventionis often needed, particularly when tissue is completely detached fromits associated bone. Currently available devices for tissue attachmentinclude screws, staples, suture anchors, and tacks. Currently availabledevices for patients of advancing age can be particularly insufficientdue to soft and weak bones leading to inadequate suture-to-anchorfixation.

Arthroscopic knot tying is commonly practiced in shoulder rotator cuffand instability procedures. Typically, an anchor loaded with suture isfirst attached to bone. The suture is normally slidably attached to theanchor through an eyelet or around a post, such that a single length ofsuture has two free limbs. One limb of the suture is passed through softtissue to be repaired such as a tendon or labrum. The two ends of thesuture are then tied to each other, thereby capturing the soft tissue ina loop with the anchor. Upon tightening the loop, the soft tissue isapproximated to the bone via the anchor.

Surgeons typically tie the suture ends using a surgical sliding knotsuch as the Tennessee Slider or Duncan Loop. After advancing the knotdistally to tighten the loop, a number of additional half hitches orother knots are tied in an effort to secure the new location of thesliding knot. The additional knots are needed because a conventionalsliding knot used in current repair constructs does not provide thenecessary protection against loosening or slippage, especially whentension is placed primarily on the limbs of the loop. The generallyaccepted practice is to follow the sliding knot with at least threereversed half hitches on alternating posts of the suture.

Before one or more half hitches or other knots can be added to thesliding knot, however, there exists a potential for the sliding knot toslip, that is, for the loop to enlarge as the tissue places tension onthe loop. This has been referred to as “loop security” and canreportedly occur even in the hands of very experienced surgeons.Sometimes, even fully-tied knots may slip. In addition to this “loopsecurity” problem, conventional knots typically have an overall sizethat can be obstructive or intrusive, especially in tight joints, whichmay damage cartilage or other tissue by abrasion with the knot.

Suture anchor systems with sliding and locking knots for repairing tornor damaged tissue include U.S. Pat. No. 6,767,037 by Wenstrom, Jr. Othersuture anchor systems suited especially for meniscal repair aredisclosed in U.S. Pat. No. 7,390,332 by Selvitelli et al. and areutilized in the OmniSpan™ meniscal repair system commercially availablefrom DePuy Mitek Inc., 325 Paramount Drive, Raynham, Mass. 02767.Screw-type anchors normally require anchor attachment before operatingsutures, which can lead to challenges related to the connection betweenthe suture and the tissue.

There are a number of suture implant systems which proclaim to be“knotless,” that is, to not require a surgeon to tie a knot duringsurgery. Many such systems control tension on tissue by the depth towhich an anchor is driven into bone. U.S. Pat. Nos. 5,782,864 and7,381,213 by Lizardi disclose certain types of suture anchors thatcapture a fixed-length loop of suture. Adjustable loop knotless anchorassemblies utilizing an anchor element inserted into a sleeve aredescribed by Thal in U.S. Pat. Nos. 5,569,306 and 6,045,574 and in U.S.Patent Application Publication No. 2009/0138042. Other systems havingclamps or other locking mechanisms include U.S. Pat. No. 5,702,397 byGoble et al. and U.S. Patent Application Publication No. 2008/0091237 bySchwartz et al. Present, so-called “knotless” designs, however,generally suffer from inadequate suture-to-anchor fixation and/orinadequate anchor-to-bone fixation, among other deficiencies.

It is therefore desirable to provide systems, devices, and methods foruse in soft tissue repair that are robust and strong, yet minimize oreliminate the number and size of knots to be tied by a surgeon,particularly during arthroscopic repair procedures.

SUMMARY

Systems, devices, and methods are generally provided for securing softtissue to bone, as well as for securing one or more objects, such as abone fragment or tissue, and for drawing two or more tissues together sothey can be secured in a desired location. In one embodiment a surgicalrepair construct includes a snare linkage, a collapsible loop, and aflexible suture pin, with the construct being configured toatraumatically pass through soft tissue to secure tissue in a knotlessmanner. The snare linkage can have a collapsible snare at a first end, asecond end that is configured to receive the collapsible loop, and aconnecting neck extending between the first and second ends. Thecollapsible loop can have a first end coupled to the second end of thesnare linkage, a sliding knot, and a collapsible filament tail thatextends from the sliding knot. The snare linkage can be made of a firstsuture filament, which can be braided or cannulated, and the collapsibleloop can be made of a second suture filament. The flexible suture pin,which can be made of a third suture filament, can have a first portionthat is removably disposed through the connecting neck and configured toprevent collapse of the snare. The pin can approximately maintain thesize of the opening of the snare when it is present in the neck toprevent premature collapse of the snare.

In some embodiments, the snare can be configured such that the firstsuture filament is coaxially disposed through itself such that at leasta portion of the connecting neck is a coaxial sliding neck that isslidable along another portion of the connecting neck. As a result, thecoaxial neck can be movable towards the second end of the snare linkageto collapse the snare and movable away from the second end of the snarelinkage to increase a size of the snare. The first portion of the suturepin can be removably disposed through the coaxial sliding neck, thusimmobilizing the coaxial sliding neck. Further, a second portion of theremovable suture pin can be disposed through a portion of the firstsuture filament that forms the collapsible snare. In such an embodiment,a stationary knot can be formed between the first and second portions ofthe suture pin at a position within a loop formed by the snare, and aterminal portion of the pin can extend beyond the loop.

In various embodiments, a thickness of the first filament can be in therange of about 20 gauge to about 32 gauge, a thickness of the secondfilament can be in the range of about 21 gauge to about 34 gauge, and/ora thickness of the third filament can be in the range of about 25 gaugeto about 40 gauge.

In some other embodiments, the snare can be formed by a second slidingknot located proximate to the connecting neck. The sliding knot can bemovable to collapse or expand a size of the snare. For example, thesliding knot can be movable away from the second end of the snarelinkage to collapse the snare and movable towards the second end of thesnare linkage to increase a size of the snare.

The second end of the snare linkage can include an eyelet, and thecollapsible loop can be coupled to the snare linkage by the eyelet.Alternatively, the collapsible loop can be coupled to the second end ofthe snare linkage by passing a portion of the collapsible loop, e.g.,the second suture filament, through a portion of the second end of thesnare linkage, e.g., the first suture filament. In some embodiments, theconstruct can include a suture shuttle filament that can be coupled tothe snare for use in advancing the snare linkage through tissue.

In some embodiments, a flexible sleeve can removably encapsulate atleast a portion of the collapsible loop, including the sliding knot. Thecollapsible filament tail can be operable to collapse the collapsibleloop when the sliding knot is moved towards the first end of thecollapsible loop. The construct can also include a terminal filamenttail formed from a portion of the second suture filament. The terminalfilament tail can extend from the sliding knot, adjacent to thecollapsible filament tail, and can be substantially stationary withrespect to the sliding knot. The construct can also include an anchorhaving a filament engagement feature. In such embodiments, a portion ofthe collapsible loop can be slidably disposed around a portion of thefilament engagement feature to couple the sliding knot to the anchorsuch that the sliding knot extends from one side of the anchor and thesnare linkage extends from another side of the anchor.

In one exemplary embodiment of a surgical repair method, the methodincludes selecting a surgical repair construct having a snare linkage, acollapsible loop, and a flexible suture pin, fixing an anchor in bone inproximity to detached soft tissue, and passing the snare linkage and aportion of the collapsible loop through a portion of the detached softtissue and around an engagement feature of the anchor. The resultingconfiguration can be one in which the snare linkage extends from oneside of the anchor and the sliding knot extends from another side of theanchor. The selected surgical repair construct can include a number offeatures, for instance, the snare linkage can have a collapsible snareat a first end, a second end that is configured to receive thecollapsible loop, and a connecting neck extending between the first andsecond ends. By way of further examples, the collapsible loop can have afirst end coupled to the second end of the snare linkage, a slidingknot, and a collapsible filament tail extending from the sliding knot,and the flexible suture pin can have a first portion that is removablydisposed through the connecting neck. The snare linkage can be made of afirst suture filament, the collapsible loop can be made of a secondsuture filament, and the flexible suture pin can be made of a thirdsuture filament.

The method can further include passing the second end of the collapsibleloop, including the sliding knot, through the snare while capturing thedetached tissue. The suture pin can be removed from the connecting neck,and the snare can be collapsed around the collapsible loop such that thesnare is distal of the sliding knot. The snare can be advanced distallytowards the bone until the snare is proximate to the tissue, and thecollapsible loop can be collapsed by moving the sliding knot distallytowards the bone to bring the tissue into proximity with the bone. Thepassing, collapsing, and advancing steps of the method can be effectedwithout tying a knot in the first or second filaments. In someembodiments, the step of advancing the snare can occur before the stepof collapsing the snare, while in other embodiments the step ofadvancing the snare can occur after the step of collapsing the snare.The step of advancing the snare distally can include tensioning thecollapsible loop. Further, in some embodiments, advancing the snaredistally by tensioning the collapsible loop can enable the snare to beadvanced distally in an incremental fashion without slackening of theconstruct. The step of collapsing the collapsible loop can includetensioning the collapsible filament tail.

In some embodiments, the method can include passing the second end ofthe collapsible loop through a second portion of the detached softtissue prior to passing the second end of the filament through thesnare. A flexible sleeve can encapsulate at least a portion of thesecond end of the collapsible loop, including the sliding knot, duringthe passing steps. The sleeve can be removed from the surgical repairconstruct prior to collapsing the collapsible loop distally towards thebone. In some embodiments, a portion of the suture pin can include aneedle attached thereto, and the suture pin can be passed through thedetached soft tissue first to pull the snare linkage through the softtissue. A portion of the suture pin can extend through the collapsiblesnare, a stationary knot can be disposed on a portion of the suture pindisposed inside a loop formed by the snare, and a terminal end of thesuture pin can extend beyond the loop of the snare, with the needlebeing attached to the terminal end. In some other embodiments, a sutureshuttle filament can be coupled to the snare, and the suture shuttlefilament can be passed through the detached soft tissue first to pullthe snare linkage through the soft tissue.

Another exemplary embodiment of a surgical repair method includesselecting a surgical repair construct having a snare linkage, acollapsible loop, and a flexible suture pin and fixing an anchor havingan engagement feature in bone in proximity to detached soft tissue. Theanchor can have a suture shuttle filament slidably coupled to theengagement feature with a first end of the suture shuttle filamentextending from one side of the anchor and a second end of the sutureshuttle filament extending from another side of the anchor. The selectedsurgical repair construct can include a number of features, forinstance, the snare linkage can have a collapsible snare at a first end,a second end that is configured to receive the collapsible loop, and aconnecting neck extending between the first and second ends. By way offurther examples, the collapsible loop can have a first end coupled tothe second end of the snare linkage, a sliding knot, and a collapsiblefilament tail extending from the sliding knot, and the flexible suturepin can have a first portion that is removably disposed through theconnecting neck. The snare linkage can be made of a first suturefilament, the collapsible loop can be made of a second suture filament,and the flexible suture pin can be made of a third suture filament.

The method can further include passing the first end of the sutureshuttle filament through a portion of the detached soft tissue andcoupling the second end of the collapsible loop to the first end of thesuture shuttle filament. A force can be applied to the second end of thesuture shuttle filament to pull the second end of the collapsible loopdistally towards the bone and to the other side of the anchor. Theresulting configuration can be one in which the snare linkage extendsfrom one side of the anchor and the sliding knot extends from anotherside of the anchor. The second end of the collapsible loop, includingthe sliding knot, can be passed through the snare while capturing thedetached tissue. The suture pin can be removed from the connecting neck,and the snare can be collapsed around the collapsible loop such that thesnare is distal of the sliding knot. The snare can be advanced distallytowards the bone until the snare is proximate to the tissue, and thecollapsible loop can be collapsed by moving the sliding knot distallytowards the bone to bring the tissue into proximity with the bone. Thepassing, collapsing, and advancing steps of the method can be effectedwithout tying a knot in the first or second filaments. In someembodiments, the step of advancing the snare can occur before the stepof collapsing the snare, while in other embodiments the step ofadvancing the snare can occur after the step of collapsing the snare.The step of advancing the snare distally can include tensioning thecollapsible loop. Further, in some embodiments, advancing the snaredistally by tensioning the collapsible loop can enable the snare to beadvanced distally in an incremental fashion without slackening of theconstruct. The step of collapsing the collapsible loop can includetensioning the collapsible filament tail.

In some embodiments, the second end of the suture shuttle can be passedthrough a second portion of the detached tissue prior to applying aforce to the second end of the suture shuttle filament to pull thesecond end of the collapsible loop distally towards the bone. The methodcan also include de-coupling the suture shuttle filament from the secondend of the collapsible loop. A flexible sleeve can encapsulate at leasta portion of the second end of the collapsible loop, including thesliding knot, during the passing steps. The sleeve can be removed fromthe surgical repair construct prior to collapsing the collapsible loopdistally towards the bone.

In one exemplary embodiment of a surgical method, the method includesselecting a flexible surgical filament having a snare at a first endthereof and an opposed leading end and positioning the surgical filamentsubstantially around an object to form a first loop. The leading end ofthe filament can be passed through the snare such that the leading endremains on one side of the snare and a second loop formed by the portionof the filament within the snare is on another side of the snare. Thesnare can be collapsed around the filament disposed therein to securethe first and second loops, with the first loop completely surroundingthe object and the second loop being adjacent to the object. The firstloop can then be collapsed around the object to engage the object withthe filament. The leading end of the filament can be passed through thesecond loop, and then the second loop can be collapsed around thefilament to secure the filament to the object. In some embodiments, thestep of collapsing the first loop around the object can include pushingthe collapsed snare towards the object. Further, in some embodiments,the step of collapsing the second loop around the filament can includetensioning the leading end of the filament.

BRIEF DESCRIPTION OF DRAWINGS

This invention will be more fully understood from the following detaileddescription taken in conjunction with the accompanying drawings, inwhich:

FIG. 1 is schematic view of one exemplary embodiment of a surgicalrepair construct;

FIG. 2 is a schematic view of one exemplary embodiment of a snarelinkage for use as part of a surgical repair construct;

FIGS. 3A-3D are sequential views of one exemplary embodiment for forminga snare of a snare linkage in which the snare has a coaxial slidingneck;

FIG. 4 is a schematic view of one exemplary embodiment of a snare of asnare linkage, the snare having a coaxial sliding neck and a flexiblemember disposed through the neck;

FIG. 5A is a schematic view of another exemplary embodiment of a snareof a snare linkage and a flexible member in which the snare has acoaxial sliding neck, this view illustrating how the flexible member canbe disposed through the neck and the snare;

FIG. 5B is a schematic view of the snare linkage and flexible member ofFIG. 5A, illustrating the flexible member disposed through the neck andthe snare;

FIG. 6 is a schematic view of an exemplary embodiment of a snare of asnare linkage and a flexible member in which the snare has a coaxialsliding neck and the flexible member is disposed through the snare;

FIG. 7 is a schematic view of another exemplary embodiment of a snare ofa snare linkage and a flexible member in which the flexible member isdisposed through a neck of the snare and a suture shuttle is loopedthrough the snare;

FIG. 8 is a schematic view of another exemplary embodiment of a snarelinkage for use as a part of a surgical repair construct;

FIG. 9 is a schematic view of another exemplary embodiment of a surgicalrepair construct;

FIG. 10 is a schematic view of the surgical repair construct of FIG. 9coupled to an anchor;

FIG. 11 is a schematic view of a suture shuttle coupled to an anchor;

FIGS. 12A-12G are sequential views of one exemplary embodiment for usingthe surgical repair construct of FIG. 10 to secure tissue to bone;

FIGS. 13A-13D are sequential views of one exemplary embodiment for usingthe suture shuttle and anchor of FIG. 11 and the surgical repairconstruct of FIG. 9 to secure tissue to bone;

FIGS. 14A-14C are sequential views of one exemplary embodiment for usinga surgical repair construct to draw two tissues closer together;

FIGS. 15A-15G are sequential views of one exemplary embodiment for usinga surgical filament to secure an object;

FIG. 16 is a schematic view of one exemplary embodiment of using asurgical filament to draw two tissues closer together;

FIG. 17 is a schematic view of one exemplary embodiment of using asurgical filament to draw a tissue closer to bone;

FIG. 18 is a schematic view of one exemplary embodiment of using twosurgical filaments to draw two tissues closer together;

FIG. 19 is a schematic view of one exemplary embodiment of using twosurgical filaments to draw a tissue closer to bone;

FIG. 20 is a schematic view of another exemplary embodiment of using twosurgical filaments to draw a tissue closer to bone;

FIG. 21 is a schematic view of one exemplary embodiment of using asurgical repair construct and a filament to draw a tissue closer tobone; and

FIG. 22 is a schematic view of another exemplary embodiment of using asurgical repair construct and a filament to draw a tissue closer tobone.

DETAILED DESCRIPTION

Certain exemplary embodiments will now be described to provide anoverall understanding of the principles of the structure, function,manufacture, and use of the devices and methods disclosed herein. One ormore examples of these embodiments are illustrated in the accompanyingdrawings. Those skilled in the art will understand that the devices andmethods specifically described herein and illustrated in theaccompanying drawings are non-limiting exemplary embodiments and thatthe scope of the present invention is defined solely by the claims. Thefeatures illustrated or described in connection with one exemplaryembodiment may be combined with the features of other embodiments. Suchmodifications and variations are intended to be included within thescope of the present invention. Further, in the present disclosure,like-numbered components of the embodiments generally have similarfeatures, and thus within a particular embodiment each feature of eachlike-numbered component is not necessarily fully elaborated upon.Additionally, to the extent that linear or circular dimensions are usedin the description of the disclosed systems, devices, and methods, suchdimensions are not intended to limit the types of shapes that can beused in conjunction with such systems, devices, and methods. A personskilled in the art will recognize that an equivalent to such linear andcircular dimensions can easily be determined for any geometric shape.Sizes and shapes of the systems and devices, and the components thereof,can depend at least on the anatomy of the subject in which the systemsand devices will be used, the size and shape of components with whichthe systems and devices will be used, and the methods and procedures inwhich the systems and devices will be used.

The figures provided herein are not necessarily to scale. Still further,to the extent arrows are used to describe a direction a component can betensioned or pulled, these arrows are illustrative and in no way limitthe direction the respective component can be tensioned or pulled. Aperson skilled in the art will recognize other ways and directions forcreating the desired tension. Likewise, while in some embodimentsmovement of one component is described with respect to another, a personskilled in the art will recognize that other movements are possible. Byway of non-limiting example, in embodiments in which a filament ispassed through itself to form a coaxial sliding neck, movement describedwith respect to the inner portion (i.e., the coaxial sliding neck asdiscussed herein) moving relative to the outer portion can likewiseinvolve movement of the outer portion with respect to the inner portion.Additionally, a number of terms may be used throughout the disclosureinterchangeably but will be understood by a person skilled in the art.By way of non-limiting example, the terms suture and filament may beused interchangeably.

Systems, devices, and methods for soft tissue repair are generallyprovided and they generally involve the use of surgical filaments thatare configured in a variety of manners to minimize and/or eliminate thetying of knots during a surgical procedure. The systems and devicesdescribed herein provide superior strength for use in a number ofdifferent surgical procedures, such as rotator cuff and instabilityrepair procedures and other types of tendon and tissue repairprocedures. They also allow for attachments that have a lower profilethan existing systems and devices, which allows for the filaments tobecome associated with tissue, for instance by passing the filamentsthrough the tissue or wrapping the filaments around the tissue, withminimal trauma to the tissue and less space being taken up by theoverall construction. This results in systems and devices that can beassociated with tissue atraumatically to secure the tissue in a knotlessmanner.

In addition to improving existing surgical procedures by providingrepair constructs that are superior in strength and performance thanexisting constructs, the systems and devices provided herein also allowfor both improved and new procedures for soft tissue repair. Forexample, the systems and devices provided herein can be used to advancetissue toward bone in an incremental fashion without the constructbacklashing to cause the tissue to move away from the bone and/or to notbe held tightly in place with respect to the bone. Further, the presentdisclosure provides for a number of different methods, some new and someimproved, for fully securing objects, such as tissue and/or bonefragments, using a single filament and for securing tissue to bone ortissue to other tissue at desired locations using one or more filamentsor repair constructs.

As shown by one exemplary embodiment of a surgical repair construct 10in FIG. 1, the constructs of the present disclosure generally include acollapsible loop 20 having a first end 22 that is coupled to a snarelinkage 40 and a second end 24 that includes a sliding knot 26 formedthereon. In the illustrated embodiment the snare linkage 40 has a snare46 at a first end 42 thereof and a second end 44 configured to receivethe first end 22 of the loop 20. The snare 46 includes an opening 48that is configured to receive the second end 24 of the loop 20 andcollapse around the second end 24 after it is disposed in the opening48. The sliding knot 26 formed on the collapsible loop 20 can beoperable to collapse a size of an opening 28 formed by the loop 20. Inparticular, the sliding knot 26 can be movable toward the first end 22to collapse the loop 20, and it can also be movable away from the firstend 22 to expand a size of the opening 28. In one embodiment, thecollapsible loop 20 and the snare linkage 40 are each formed bydifferent surgical filaments.

As shown, the collapsible loop 20 can include two tails, a collapsibletail 30, operable to move the sliding knot 26 towards the first end 22in a ratchet-like or incremental manner, and a stationary terminal tail32 configured to remain stationary with respect to the sliding knot 26.The construct 10 can be passed through one or more tissues such thatpassing the second end 24 through the snare 46 and both collapsing thesnare 46 around the second end 24 and advancing the snare 46 distally(e.g., toward bone) can cause the tissue through which the construct 10is disposed to be drawn toward a bone, an anchor, or other tissue towhich the construct 10 is also coupled, as described in greater detailbelow. Because of the features of the constructs disclosed herein, manyrepair methods can be performed atraumatically and without tying knotsto attach and move tissue to desired locations during the course of asurgical procedure.

FIG. 2 provides one exemplary embodiment of a snare linkage 140 for useas part of a surgical repair construct. A first end 142 of the snarelinkage 140 can include a snare 146 that is configured to collapse undertension, a second end 144 of the snare linkage 140 can be configured toslidably couple to a collapsible loop 120 of the construct to allowrelative motion between the linkage 140 and the loop 120, and aconnecting neck 150 can extend between the two ends 142, 144. As shownin FIG. 2, the connecting neck 150 can be formed by a surgical filamenthaving a coaxial sliding neck 152 that is slidable within a cannulatedportion 154 of the connecting neck 150. Movement of the coaxial slidingneck 152 in approximately a first direction A, away from the second end144, can expand a size of the snare opening 148, while movement of thecoaxial sliding neck 152 in approximately a second direction B, towardthe second end 144, can collapse the snare opening 148. A person skilledin the art will recognize that the coaxial sliding neck 152 moves withrespect to the cannulated portion 154, and thus although the movement isdescribed herein based on the movement of the coaxial sliding neck 152,the cannulated portion 154 can also be slid with respect to the coaxialsliding neck 152. Passing the filament that forms snare linkage 140through itself to form the coaxial sliding neck 152 allows the snarelinkage 140 to have a low profile that minimizes and/or eliminates thetrauma associated with passing the snare linkage 140 through tissue,particularly in comparison to existing surgical repair constructs.Further, this construction can eliminate any sharp features that couldbe present in existing surgical repair constructs, which can presentdifficulties, including trauma, when trying to pass surgical repairconstructs through tissue.

FIGS. 3A-3D illustrate one method of forming snare linkage 140′ having asnare 146′ and a coaxial sliding neck 152′ for use in a surgical repairconstruct. In this exemplary embodiment, the snare 146′ is formed from abifurcated suture filament having a tubular portion 153′ with a coreremoved therefrom to form a cannulated portion 154′ and first and secondterminal limbs 156′, 158′. As shown in FIG. 3B, the terminal limbs 156′,158′ can be curled back toward the tubular portion 153′ to form a loophaving an opening 148′ that defines the snare 146′. As shown in FIG. 3C,a bore 160′ can be formed on a side of the tubular portion 153′ and theterminal limbs 156′, 158′ can be placed into the cannulated tubularportion 154′ through the bore 160′. Ends of the terminal limbs 156′,158′ can be fed through the cannulated portion 154′, and as shown inFIG. 3D, the terminal limbs 156′, 158′ can be pulled distally (directionC in FIG. 3D) through the tubular portion 153′ such that the tubularportion 153′ is fed through itself. Accordingly, the snare 146′ can becollapsed by tensioning the limbs 156′, 158′ in approximately a firstdirection C, and/or the coaxial portion of the tubular portion 153′ thatextends outside of the connecting neck 150′, and the snare 146′ can beexpanded by applying a force to the snare 146′ in approximately asecond, opposite direction D, which pulls the limbs 156′, 158′ towardsthe snare 146′.

The sizes of the components of the snare linkage 140′ can depend, atleast in part, on the procedure in which it is being used, thecomponents with which it is being used, and other factors recognized bythose skilled in the art. In one embodiment the overall length of thesnare linkage can be in the range of about 5 millimeters to about 50millimeters, and in one embodiment it is about 36 millimeters. Further,in embodiments in which the snare linkage is formed of a filament havingterminal limbs that extend through coaxially through a connecting neck,such as the embodiment shown in FIGS. 3A-3D, a length of the filamentused to form the snare linkage can be in the range of about 15centimeters to about 125 centimeters, and in one embodiment it is about60 centimeters.

Snares can also be formed in a number of other manners known to thoseskilled in the art. For example, a number of different sliding knots canbe used to form the snare of the snare linkage, including but notlimited to a Buntline Hitch, a Tennessee Slider, a Duncan Loop, and aHangman's Noose. To the extent the sliding knot used to form a snareaffects the operation of the snare, for instance whether a limb ispulled through a knot to change the position of the knot or a knot isslid along a limb to change the position of the knot, a person skilledin the art would be able to adapt these types of knots for use with theteachings of the present invention without departing from the spirit ofthe present disclosure. As described herein, unless otherwisedesignated, a knot used to form a snare in a snare linkage is movableaway from a second end of the snare linkage, i.e., away from thecollapsible loop, to collapse the snare and towards the second end,i.e., towards the collapsible loop, to increase a size of the snare.

The snare linkage can be made of a variety of materials, but in oneexemplary embodiment the snare linkage is formed using a surgicalfilament, such as a cannulated filament, a braided filament, and a monofilament. The type, size, and strength of the filament can depend, atleast in part, on the other materials of the system, including thematerial(s) of the collapsible loop with which it is used, the tissueand other components through which it will be passed or coupled to, andthe type of procedure in which it is used. In one exemplary embodimentthe snare linkage is formed from a #2 filament (about 23 gauge to about24 gauge), such as an Orthocord™ filament that is commercially availablefrom DePuy Mitek, Inc. or an Ethibond™ filament that is commerciallyavailable from Ethicon, Inc., Route 22 West, Somerville, N.J. 08876. Thecores of these filaments can be removed to form a cannulatedconfiguration if desired. The thickness of the snare linkage shouldprovide strength in the connection but at the same time minimize thetrauma caused to tissue through which it passes. In some embodiments thesnare linkage can have a size between about a #5 filament (about 20gauge to about 21 gauge) and about a #3-0 filament (about 29 gauge toabout 32 gauge). The Orthocord™ #2 filament can be useful because it hasa braided configuration, which allows other components, such as flexiblemembers or collapsible loops as discussed below, to pass throughsubcomponents of the braid without causing damage to the filament.Filaments configured to allow for a cannulated configuration, such as byremoving a core therefrom or having a pre-formed cannulatedconfiguration, can also be used to form the snare linkage. Orthocord™suture is approximately fifty-five to sixty-five percent PDS™polydioxanone, which is bioabsorbable, and the remaining thirty-five toforty-five percent ultra high molecular weight polyethylene, whileEthibond™ suture is primarily high strength polyester. The amount andtype of bioabsorbable material, if any, utilized in the filaments of thepresent disclosure is primarily a matter of surgeon preference for theparticular surgical procedure to be performed.

In use, the length of portions of the snare linkage, and in particularthe snare and the connecting neck, can change as the snare is collapsed.In one exemplary embodiment, a diameter of the snare opening in anuncollapsed position is in the range of about 2 millimeters to about 15millimeters, and in one embodiment it is about 10 millimeters while alength of the connecting neck when the snare is in an uncollapsedconfiguration is in the range of about 0 millimeters (excluding thelength of the connecting neck) to about 45 millimeters (excluding thelength of the connecting neck), and in one embodiment it is about 5millimeters (excluding the length of the connecting neck). A length ofthe neck after the snare is collapsed, on the other hand, can be in therange of about 3 millimeters (excluding the length of the connectingneck) to about 45 millimeters (excluding the length of the connectingneck), and in one embodiment is about 27 millimeters (excluding thelength of the connecting neck).

Because the connecting neck, and particularly the sliding neck 152 andthe cannulated portion 154, can allow the snare to both expand andcontract, a flexible member, such as a suture pin, can be removablydisposed across the neck to prevent unintentional movement of the snareas the snare passes through an obstruction, such as tissue. Inembodiments in which a connecting neck 250 (FIG. 4) includes a coaxiallysliding neck 252, such as in the snare 246 of a snare linkage 240illustrated in FIG. 4, a flexible member 270 can extend across the neck250 to immobilize the coaxially sliding neck 252 with respect to theconnecting neck 250. Once the snare 246 is passed through theobstruction and the risk of unintentional and premature expansion orcollapse is reduced, the flexible member 270 can be removed. The use ofa flexible member of the type described herein to prevent unintentionalcollapse of the snare in tissue repair procedures is advantageous as itcan allow the snare linkage to be passed atraumatically through tissuewhile still preventing unintentional collapse of a snare.

In another embodiment, shown in FIGS. 5A and 5B, a flexible member 370can both immobilize a snare 346 of a snare linkage 340 and serve as asuture shuttle to guide the snare linkage 340 through obstructionsduring the course of a procedure. As shown in FIG. 5A, a first end 372of the flexible member 370 can be passed across connecting and coaxialnecks 350, 352 of the snare linkage 340 so that a first portion of theflexible member 370 is disposed through the neck 350, while a second end374 of the flexible member 370 is passed through and disposed in thesnare 346. A protrusion 376, for instance a stationary knot that can bepre-formed or formed or modified during a procedure, can be disposed onthe flexible member 370 at a location between the first and second ends372, 374. The protrusion 376 can serve to maintain the flexible member370 in a coupled arrangement with the snare linkage 340, and as shown inFIG. 5B, the protrusion 376 can be disposed within the opening or loop348 formed by the snare 346, abutting a surface of the snare, with aterminal portion 378 extending through and beyond the loop 348 for useas a shuttle. Optionally, a needle or similar tool or device can becoupled to the terminal portion 378 to assist in threading the snarelinkage 340 through tissue.

Other configurations in which a flexible member is used as both a suturepin and a suture shuttle are also possible, depending, at least in part,on the configuration of the snare linkage and obstructions though whichthe snare linkage will be passed, without departing from the spirit ofthe present disclosure. For example, the flexible member 370 can bedisposed through another portion of the connecting neck 350 or adifferent portion of the snare 346. One benefit of using a flexiblemember for both maintaining a snare shape and shuttling the snarelinkage is that it can improve filament management by limiting thenumber of filaments used in a procedure. Further, such a constructionallows for a single action to remove both the pin and the shuttle fromthe linkage, such as applying tension to a second terminal end 379 ofthe flexible member 370 to decouple the flexible member 370 from thesnare linkage 340.

In still other embodiments a flexible member can be used primarily forthe purpose of shuttling the snare linkage through obstructions. FIGS. 6and 7 illustrate two examples of ways a flexible member 470, 470′ can becoupled to a snare linkage 440, 440′ for shuttling purposes. As shown inFIG. 6, the flexible member 470 is passed across a top portion 447 ofthe snare 446, with a protrusion 476 being formed on the flexible member470 to maintain a coupling between the flexible member and the snareassembly during shuttling. The protrusion 476 can be disposed within theopening or loop 448, abutting a surface of the loop, with a terminalportion 478 extending through and beyond the loop 448 for use as ashuttle. A needle or similar tool or device can optionally be coupled tothe terminal portion 478 to assist in threading the snare linkage 440through tissue. Although not illustrated, it can be helpful to includeanother flexible member disposed across a connecting neck 450 of thesnare linkage 440 to immobilize a coaxially sliding neck 452 disposedtherein while the snare linkage 440 is being shuttled throughobstructions.

As shown in FIG. 7, a first flexible member 470′ is coupled to a snarelinkage 440′ by looping the flexible member 470′ through a snare 446′,and a second flexible member 471′ is disposed across a connecting neck450′ to immobilize the neck 450′ while the snare linkage 440′ is beingshuttled through obstructions. In the absence of a flexible member 471′across the neck 450′, or other suture pin mechanism in its place,tension applied to the first flexible member 470′ in approximately adirection F to shuttle the snare linkage 440′ through obstructions wouldcause the size of the snare opening 448′ to decrease.

The flexible member(s) for any of the embodiments described herein canbe made of a variety of materials, but in one exemplary embodiment it isa surgical filament that is separate from the surgical filament thatforms the snare linkage. In some embodiments the flexible member isformed using a surgical filament, such as a cannulated filament, abraided filament, and a mono filament. The type, size, and strength ofthe filament can depend, at least in part, on the other materials of thesystem, including the material(s) of the neck through which it willpass, the obstructions through which the snare will pass, how thefilament is being used (e.g., as a suture pin, as a suture shuttle, oras a joint suture pin and suture shuttle), and the type of procedure inwhich it is used. In one exemplary embodiment the flexible member isformed from a #2-0 filament (about 28 gauge), such as an Orthocord™filament that is commercially available from DePuy Mitek, Inc. orEthibond™ filament available from Ethicon Inc. Generally the flexiblemember is relatively thin to minimize any trauma to tissue through whichit passes, and typically the flexible member is thinner than the snarelinkage. In some embodiments the flexible member can have a size betweenabout a #1 filament (about 25 gauge to about 26 gauge) and about a #6-0filament (about 38 gauge to about 40 gauge). A length of the flexiblemember can be in the range of about 1 centimeter to about 100centimeters. In one embodiment in which the flexible member is onlybeing used as a suture pin it can have a length of about 1 centimeter.In one embodiment in which the flexible member is used as both a suturepin and a suture shuttle it can have a length of about 50 centimeters.In one embodiment in which the flexible member is only being used as asuture shuttle it can have a length of about 100 centimeters.

A person skilled in the art will appreciate that a number of differentconfigurations can be used to slidably mate a collapsible loop with asnare linkage. Two such embodiments are shown in FIGS. 2 and 8. As shownin FIG. 2, the second end 144 of the snare linkage 140 includes aneyelet 180 configured to receive the collapsible loop 120. The eyelet180 is generally circular in shape, and can generally have asubstantially fixed diameter. The eyelet 180 can be formed in any numberof ways, but in one embodiment in which the snare linkage 140 is formedfrom a cannulated or braided surgical filament, a first portion 182 ofthe filament can be passed through a second portion 184 to form theeyelet 180, similar to the formation of the snare 146 at the first end142. However, to maintain a substantially fixed diameter, the firstportion 182, which serves as a coaxially sliding neck, can be fixed withrespect to the second portion 184, which serves as an outer neck. Anynumber of techniques can be used to fix the location of the sliding neck182, including using an adhesive, heat bonding the filament, ordisposing a pin or other fasteners thereacross. By passing the filamentthrough itself to form the eyelet 180, the snare linkage 140 maintains alow profile at the second end 144. While a size of the eyelet candepend, at least in part, on the other components of the construct, theobstructions through which the snare linkage will pass, and the type ofprocedure in which it is used, a diameter of the eyelet can be in therange of about 1 millimeter to about 10 millimeters, and in oneembodiment it is about 3 millimeters.

FIG. 8 provides an alternative configuration for a second end 544 of asnare linkage 540. As shown, a collapsible loop 520 is coupled to thesnare linkage 540 by passing the loop 520 through the filament at thesecond end 544. The filament that forms snare linkage 540 can be acannulated filament, a braided filament, or a mono filament that enablesthe loop 520 to pass through the filament and maintain a slidingengagement therewith without causing damage to filament of the snarelinkage 540 or the loop 520. One skilled in the art will appreciate thatsecond end 544 of the filament can be treated to prevent unintendedfraying. For example, the second end of the filament can be heat bonded,coated, or otherwise treated to prevent fraying. Alternativeconfigurations and materials beyond those provided in FIGS. 2 and 8 canalso be used by those skilled in the art to allow for a slidingengagement between the second end of the linkage and the collapsibleloop.

Although in the illustrated embodiments the snare is part of aseparately formed snare linkage, in other embodiments a single filamentcan be used to form both the snare and the collapsible loop. Othertechniques can also be used to form the snare and loop, including thosediscussed in U.S. patent application Ser. No. 13/218,810 filed Aug. 26,2011, and entitled “SURGICAL FILAMENT SNARE ASSEMBLIES,” the content ofwhich is incorporated by reference herein in its entirety.

The collapsible loop 20 illustrated in FIG. 1 can generally be aflexible elongate member having a first end 22 coupled to the snarelinkage 40 and a second end 24 closed by a sliding knot 26. The slidingknot 26 allows the loop 20 to be collapsed as desired, and thus when aportion of the loop 20 is coupled to or passed through tissue,collapsing the loop 20 can tension the tissue to draw it toward adesired location. As shown in FIG. 1, as the knot 26 is moved toward thefirst end 22, the loop 20 collapses, and as the knot 26 is moved awayfrom the first end 22, the size of the opening 28 of the loop 20increases. The sliding knot 26 can be formed in a variety of ways usinga variety of techniques well known to those skilled in the art.Non-limiting examples of the types of knots that can be used as theloop's sliding knot include a Buntline Hitch, a Tennessee Slider, aDuncan Loop, a Hangman's Noose, and a loop having a coaxial slidingneck.

As shown in FIG. 1, the loop 20 can also have a collapsible tail 30 anda stationary terminal tail 32 that extend from the sliding knot 26. Thetails 30, 32 can be terminal ends of two limbs of a filament used toform the sliding knot 26 that completes the collapsible loop 20. Thecollapsible tail 30 can be operable to tension and collapse the loop 20by moving the sliding knot 26 towards the loop first end 22. Moreparticularly, applying tension to the collapsible tail 30 inapproximately the direction E can cause the knot 26 to slide distallytoward the first end 22. As a result, the sliding knot 26 can move in aratchet-like or incremental fashion such that the knot 26 moves towardthe first end 22 without backlashing and causing the collapsible loop 20to increase in size. When tension is not applied, the location of thesliding knot 26 remains substantially fixed, and further tensioning ofthe collapsible tail 30 can cause further distal movement of the knot 26until either the tension is released or an obstruction precludes furtherdistal movement of the knot 26. The self-locking capabilities providedby this sliding knot 26 that result from the overall formation of theconstruct 10 are beneficial at least because of the ability toincrementally advance the knot 26 without backlashing.

As shown, the stationary terminal tail 32 is adjacent to the collapsiblefilament tail 30 and is stationary with respect to the sliding knot 26.In the illustrated embodiment the stationary terminal tail 32 is shorterthan the collapsible tail 30, but in other instances it can be the samelength as or even longer than the collapsible tail 30. A longerstationary tail 32 can provide some beneficial aspects. For example, insome embodiments, a long stationary tail 32 can be used as a sutureshuttle to pass the collapsible loop 20 through tissue. Using thestationary tail 32 as a shuttle can prevent a premature collapse of theloop 20. In such embodiments, a needle or similar tool or device canoptionally be coupled to the stationary tail 32 to assist in threadingthe tail 32 through tissue. Further, once a procedure is completed usingthe construct 10 that has a longer stationary tail 32, one or morehalf-hitches can optionally be formed on the stationary tail 32 toprovide additional system strength. Such half-hitches can also be formedon the collapsible tail 30 if desired for additional strength. Stillfurther, longer stationary and collapsible tails 32, 30 can be used inconjunction with other types of procedures, such as double rowprocedures, as described in greater detail below.

Similar to the other components of the surgical repair construct, theflexible loop can be made of a variety of materials, but in oneexemplary embodiment it is a surgical filament. The surgical filamentthat forms the collapsible loop is typically a separate filament thanwhat is used to form the snare linkage or the flexible member. Further,the filament of the collapsible loop can be any suitable suture materialsuch as a cannulated filament, a braided filament, and a mono filament.The type, size, and strength of the filament can depend, at least inpart, on the other materials of the system, including the materials ofany snare linkage or bone anchor with which the loop may be associated,the obstructions through which the loop will pass, and the type ofprocedure in which it is used. In one exemplary embodiment the flexibleloop is formed from a #0 filament (about 26 gauge to about 27 gauge),such as an Orthocord™ filament that is commercially available from DePuyMitek, Inc or Ethibond™ filament available from Ethicon, Inc. Generallythe collapsible loop is relatively thin to minimize any trauma to tissuethrough which it passes, and can typically the loop is thinner than thesnare linkage. In some embodiments the collapsible loop can have a sizebetween about a #4 filament (about 21 gauge to about 22 gauge) and abouta #4-0 filament (about 32 gauge to about 34 gauge). A length of the loopin its uncollapsed configuration can be in the range of about 2centimeters to about 60 centimeters, and in one embodiment it can beabout 40 centimeters. Still further, a diameter of the sliding knot ofthe loop will depend, at least in part, on the size of the filament usedto form it, the type of sliding knot that it is, and the type ofprocedure with which it will be used. In one exemplary embodiment adiameter of the sliding knot can be in the range of about 0.5millimeters to about 3 millimeters, and in one embodiment it can beabout 1 millimeter.

Optionally, a flexible sleeve can be provided for encapsulating at leasta portion of a collapsible loop. As shown in FIG. 9, in one embodimentof a repair construct 610, a sleeve 690 can be disposed aroundcollapsible and stationary terminal tails 630, 632, a sliding knot 626,and a portion of the loop 620 at a second end 624, extending toward afirst end 622. The sleeve 690 can have a generally cylindricalconfiguration and can be flexible to allow it to bend as shown invarious embodiments provided herein. The sleeve 690 can be useful whenpassing the construct 610 through obstructions such as tissue for anumber of reasons. The sleeve 690 can protect the knot 626 from beingunintentionally tightened when it passes through an obstruction.Further, the sleeve 690 can be configured to have a smoother surfacethat is better configured to pass through tissue than a knot, thuseasing trauma caused by passing the construct 610 through tissue. Stillfurther, because the sleeve 690 can encapsulate a plurality of filamentlimbs, the sleeve 690 can ease filament management by maintaining thefilaments within the enclosed sleeve 690. The sleeve 690 can beremovable, and it is typically removed prior to collapsing the loop 620so that the sleeve 690 does not interfere with movement of the slidingknot 626.

FIG. 9 illustrates only one of many possible configurations of whichportions of the construct 610 can be encapsulated by the sleeve 690. Insome embodiments, one or both of the collapsible and stationary terminaltails 630, 632 can extend beyond the sleeve 690. Alternatively, thesleeve 690 can extend a length beyond terminal ends of the collapsibleand stationary terminal tails 630, 632 such that a portion of the sleeve690 is empty. A configuration of this nature can aid a surgeon inpulling the construct 610 through a portion of the body by providingextra length onto which he or she can grasp. Preferably the sleeve 690can extend outside of a body and a cannula placed in the body once theconstruct 610 is implanted so the sleeve 690 can be easily removed.

The sleeve can be made from a wide variety of biocompatible flexiblematerials, including a flexible polymer or it can be another filament.In one embodiment, the sleeve is made of a polymeric material. Inanother embodiment, the sleeve is a flexible filament, such as a braidedsuture, for example Ethibond™ #0 filament or Orthocord™ #2 filament,which is typically braided at sixty picks per 2.54 centimeters. For useas a sleeve, a more relaxed braid of approximately thirty to forty picksper 2.54 centimeters is preferred, more preferably about 36 picks per2.54 centimeters. If the sleeve material is formed about a core,preferably that core is removed to facilitate insertion of the filamentlimbs, which may themselves be formed of typical suture such asOrthocord™ #0 suture or #2 suture braided at sixty picks per 2.54centimeters. Additional convenience can be provided by perceptibleindicators on the sleeve such as different markings, colors, diameters,braid or design patterns, or other tactile or visual indicia, especiallyif multiple tissue attachments or anchors are utilized.

A length and diameter of the sleeve can depend, at least in part, on thesize and configuration of the components of the construct with which itis used, the obstructions through which the sleeve may pass, and thesurgical procedure in which it is used. In any event, the sleeve istypically of a size such that it can pass atraumatically through tissue.In embodiments in which the sleeve is a filament, a size of the sleevecan be in the range of about a #5 filament (about 20 gauge to about 21gauge) to about a #2-0 filament (about 28 gauge), and in one embodimentthe size can be about a #0 filament (about 26 gauge to about 27 gauge).A person having skill in the art will recognize comparable diametersizes that can be used in instance in which the sleeve is made of apolymeric or other non-filament material. The sleeve can have a lengthin the range of about 10 centimeters to about 60 centimeters, and in oneembodiment it has a length of about 40 centimeters.

FIG. 10 illustrates one exemplary embodiment of the repair construct 610of FIG. 9 coupled to a bone anchor 608. One skilled in the art willappreciate that a variety of bone anchor types can be used inconjunction with the constructs provided herein. However, for purposesof illustration, anchor 608 is a Healix Ti™ anchor that is commerciallyavailable from DePuy Mitek, Inc. The anchor 608 can include a filamentengagement feature 609, which can be on any part of the anchor, but inthe exemplary embodiment is at a distal end 608 d of the anchor 608 andallows the construct 610 to be slidably engaged with the anchor 608.Regardless of the type of anchor used, the construct 610 should beslidingly coupled to the anchor 608 by way of the filament engagementfeature 609 such that the snare linkage 640 extends from one side of theanchor 608 and the sliding knot 626 extends from the other side of theanchor 608. The use of this construct 610 is described below withrespect to FIGS. 12A-12G.

FIG. 11 illustrates one exemplary embodiment of a suture shuttle 800coupled to a bone anchor 708. Again, virtually any type of bone anchorcan be used in conjunction with the shuttles and constructs providedherein, but the illustrated anchor 708 is a Healix Ti™ anchor that iscommercially available from DePuy Mitek, Inc. The anchor 708 can includea filament engagement feature 709, which can be at a distal end 708 d ofthe anchor 708 and which allows the shuttle 800 to be slidably engagedwith the anchor 708. As shown, the shuttle 800 is slidingly coupled tothe anchor 708 at the filament engagement feature 709 such that a firstend 802 of the shuttle 800 extends from one side of the anchor 708 and asecond end 804 of the shuttle 800 extends from the other side of theanchor 708. The first end 802 can be configured to be coupled to arepair construct, such as the repair construct 610 of FIG. 9. As shown,the first end 802 includes a collapsible snare 806, but any othersuitable coupling mechanism can be used at the first end 802 withoutdeparting from the spirit of the present disclosure. For example, thefirst end 802 can include a clip or a like element to clamp around arepair construct. Once the repair construct 610 is coupled to the firstend 802, the second end 804 can be used to position the repair construct610 in a desired location as described below with respect to FIGS.13A-13D.

One exemplary embodiment of a method for performing a rotator cuffrepair using the repair construct illustrated in FIG. 10 is illustratedin FIGS. 12A-12G. A surgical opening can be formed through skin 1000 anda cannula can be passed therethrough to create a surgical repair site ina manner well known to those skilled in the art. Although cannulas areoften used to define a channel through which the procedure can beperformed, the cannula is not shown in FIGS. 12A-12G for ease ofillustration. Accordingly, to the extent the figures show components ofthe systems and devices passing through skin 1000, these componentswould typically be extending through the cannula, which itself is passedthrough the skin 1000. Further, although the devices and methodsdescribed herein are particularly useful for minimally invasive surgery,such as arthroscopic surgery, they can also be used in open surgicalprocedures.

As shown in FIG. 12A, the anchor 608 shown in FIG. 10 can be fixatedinto bone 1001 using ordinary techniques, such as with a driver to screwor tap the anchor 608 into place. In the illustrated embodiment theconstruct 610, which includes a flexible member 670 that serves as botha suture pin and a shuttle, is already coupled thereto, although inother embodiments the construct 610 can be slidingly coupled to theanchor 608 after the anchor 608 is positioned at its desired location.

As shown in FIGS. 12B and 12C, a terminal portion 679 of the flexiblemember 670 can be passed into and through tendon 1003 detached from bone1001 to pull the snare linkage 640, and a portion of the collapsibleloop 620, through the tendon 1003. Optionally, a needle or similar toolor device can be coupled to the terminal portion 679 to assist withthreading the construct 610 through the tendon 1003. Likewise, othershuttling techniques, including those described herein and those knownto a person skilled in the art, can also be used to pass the snarelinkage 640 through and/or around the tendon 1003. The other end of theconstruct 610 on which the sliding knot 626 is disposed can also passthrough the tendon 1003 at a second location on the tendon 1003. Asshown, the optional sleeve 690 can be disposed around the limbs 630,632, the sliding knot 626, and a portion of the loop 620, thereby easingany trauma caused by passing this portion of the construct 610 throughthe tendon 1003 and assisting with management of the filament limbs. Asa result, on one side of the anchor 608 is the snare linkage 640 thathas been passed through the tendon 1003 at a first location and isaccessible to the surgeon outside of the body, and on the other side ofthe anchor 608 is the sliding knot 626 that has been passed through thetendon 1003 at a second location and is accessible to the surgeonoutside of the body.

As shown in FIG. 12D, a portion of the loop second end 624 can be passedthrough the snare 646 such that the snare 646 is distal of the slidingknot 626, thereby allowing the tendon 1003 through which the construct610 is disposed to be captured. The flexible member 670 can be removedfrom the snare linkage 640, and the snare 646 can be collapsed ordressed around the portion of the second end 624 that is disposedtherethrough, with the snare 646 remaining distal of the sliding knot626. The flexible member 670 can actually be removed from the snarelinkage 640 any time after it has been passed through any tissue suchthat its purposes of serving as a shuttle for the construct 610 and apin to prevent unintentional collapse of the snare 646 are no longerdesired.

As shown in FIG. 12E, tension can be applied to the second end 624 bypulling approximately in a direction G, thereby causing the collapsedsnare 646 to slide distally toward the tendon 1003 in a zip-line likemanner until the snare 646 is adjacent to the tendon 1003.Alternatively, tension can be applied to the second end 624 before thesnare 646 is dressed and after the snare 646 is adjacent to the tendon1003, or some combination of the two actions can be used, such aspartially dressing the snare 646 before zip-lining it toward the tendon1003. As shown in FIG. 12E, when the snare 646 is collapsed, additionalfilament that was previously part of the snare 646 forms an elongatedconnecting neck 651 between the first and second ends of the snarelinkage 640. As shown, a portion of this elongated connecting neck 651can become disposed around the filament engagement feature 609.

If a sleeve 690 is included as part of the construct 610, it can beremoved once it is used to assist in passing the second end of theconstruct 610 through tissue. However, it can be helpful to keep thesleeve 690 disposed around a portion of the loop second end 624 toprevent unintentional movement of the knot 626, to continue helping tomanage filament limbs, and to help in zip-lining the snare 646 towardthe tendon 1003 because there is typically less friction created by thesleeve 690 as opposed to the filament that the sleeve 690 encapsulates.As shown in FIG. 12F, once the sleeve 690 is no longer desired, it canbe removed from the construct 610 to expose the sliding knot 626 and thecollapsible tail 630. Tension can be applied to the collapsible tail 630by pulling approximately in the direction H, thereby causing the knot626 to advance distally towards the tendon 1003 so that it can beadjacent to the snare 646 and in turn bring the tendon 1003 intoproximity with the bone 1001, as shown in FIG. 12G. The configuration ofthe construct 610 allows the knot 626 to be advanced in an incremental,ratchet-like fashion when the collapsible tail 630 is pulled in thedirection H without the risk of reversing the progress of the knot 626as a result of slipping backward, sometimes referred to as backing out,backlashing, or slackening of the filament. Alternatively, in anembodiment in which no sleeve is used and thus the knot 626 is free toslide, the snare 646 and the loop 620 can be collapsed at the same timeby applying tension to the collapsible tail 630 approximately in thedirection H.

As shown in FIG. 12G, optionally, one or more half-hitches 631 can beadded to the filament adjacent to the sliding knot 626 to provideadditional strength once the filaments have been finally positioned toapproximate tissue. The half-hitches 631 can be formed on either or bothof the collapsible and stationary terminal tails 630, 632. The formationof one or more half-hitches, however, can hinder the ability for thecollapsible tail 630 to provide the incremental movement of the slidingknot 626. Accordingly, in instances in which multiple constructs areused together as part of a procedure, it may be desirable to addhalf-hitches only after all constructs have been placed, deployed, andtensioned as desired. Other than the optional half-hitches, no knotsneed to be tied during the course of the illustrated procedure.

Further, as also illustrated, the excess portions of either or both ofthe tails 630, 632 can be removed if desired. The stitch patternresulting from the methods and shown in FIG. 12G is a mattress stitchpattern, but a person skilled in the art would be able to use otherdesired stitch patterns without departing from the spirit of the presentdisclosure. The resulting break strength of the formed stitch can be inthe range of about 130 Newtons to about 225 Newtons without theformation of any half-hitches, and in one embodiment the break strengthcan be about 156 Newtons without the formation of any half-hitches. Theuse of half-hitches typically increases the load capacity.

Although in the illustrated embodiment the stationary terminal tail 632is short, in other embodiments it can be longer for reasons describedabove and for other procedures. By way of non-limiting example, in oneprocedure, after the snare 646 and sliding knot 626 have been advancedto be adjacent to the tendon 1003, at least one half-hitch can be addedto the stationary terminal tail 632 and then the remaining length of thetail 632 can be used for medial row fixation in a double row proceduresuch that two tails 630, 632 can be spanned over to medial rowanchor(s). By way of further non-limiting example, a collapsing tail 630can be spanned over to a lateral row anchor without locking the repairconstruct with an additional half-hitch. In this instance, however, themedial and lateral row fixations would not be independent of each other.

Further modifications to the method described with respect to FIGS.12A-12G can include slidably coupling multiple repair constructs to thesame anchor, which would provide the ability to incrementally andindependently tension each construct with respect to the same anchor.Accordingly, a new repair technique can be implemented in which thetension on the whole repair construct can be tailored incrementally toeliminate undesired blemishes such as puckering and the formation of“dog-ears.” Alternatively, multiple anchors, each having one or morerepair constructs slidably coupled thereto, can be disposed at thesurgical site and again incremental repair can be tailored for a moredesirable result.

One exemplary embodiment of a method for performing a rotator cuffrepair using the repair construct illustrated in FIGS. 9 and 11 isillustrated in FIGS. 13A-13D. A surgical opening can be formed throughskin 1000 and a cannula can be passed therethrough to create a surgicalrepair site according to well known techniques. Similar to FIGS.12A-12G, although cannulas are often used to define a channel throughwhich the procedure can be preformed, the cannula is not shown in FIGS.13A-13D for ease of illustration. Accordingly, to the extent the figuresshow components of the systems and devices passing through skin 1000,these components would typically be extending through the cannula, whichitself is passed through the skin 1000.

As shown in FIG. 13A, the anchor 708 shown in FIG. 11 can be fixatedinto bone 1001 using ordinary techniques, such as by using a driver toscrew or tap the anchor 708 into place. In the illustrated embodimentthe suture shuttle 800, which includes the first end 802 having thesnare 806 formed therein, is already coupled thereto, although in otherembodiments the suture shuttle 800 can be slidingly coupled to theanchor 708 after the anchor 708 is positioned at its desired location.

As shown in FIG. 13B, the first and second ends 802, 804 of the sutureshuttle 800 can be passed through detached soft tissue, such as tendon1003. As shown in FIG. 13C, a portion of the repair construct 610 ofFIG. 9 can be passed through the snare 806. The snare 806 can then becollapsed, thereby coupling the repair construct 610 to the shuttle 800.Although the snare 806 is the mechanism used to couple the shuttle 800and the construct 610, a variety of other coupling techniques can alsobe used to couple the repair construct 610 to the suture shuttle 800. Aforce approximately in the direction J can then be applied to the secondend 804 to pull the first end 802, and thus the repair construct 610,through the tendon 1003 at a first location, around the filamentengagement feature 709, and through the tendon 1003 at a secondlocation. As a result, the snare linkage 640 can be disposed on one sideof the anchor 708 and the sliding knot 626 can be disposed on the otherside of the anchor 708, with the collapsible loop 620 being slidinglyengaged with the filament engagement feature 709. The optional,removable sleeve 690 can be particularly useful in this embodimentbecause the knot 626 passes through the tendon 1003 twice, and alsoaround the anchor 708, and thus the less friction and suture managementcapabilities it affords can be helpful. Further, once the shuttle 800has moved the construct 610 to the desired location, the shuttle 800 canbe de-coupled from the repair construct 610. Once the construct 610 isin place as illustrated in FIG. 13D, the construct 610 can be operatedin a manner similar to as described with respect to FIGS. 12D-12G.

In some embodiments, the anchor 708 can include multiple suture shuttlescoupled thereto to allow for multiple repair constructs that can beindependently and sequentially deployed to be used in a surgicalprocedure. Alternatively, a surgeon can use a single shuttle to installmultiple constructs on the same anchor, or still further, multipleanchors can be fixated for a procedure with each having its own repairconstruct or shuttle, or one suture shuttle can be used to place one ormore constructs at multiple anchors.

Although in the illustrated embodiments the construct 610 is passedthrough two portions of tendon 1003, alternatively the construct 610 canbe passed through only one portion of tendon or tissue while the secondportion of the construct 610 can be free of the tendon or tissue. Eitherof the two ends can be the end that is not passed through the tendon ortissue, however, if a snare linkage 640 is not passed through tissue, aflexible member 670 to serve as a suture pin can be omitted and can bereplaced, if desired, by any technique or mechanism used to preventunintentional collapse of the snare 646, such as a spacer or tube. Stillfurther, rather than passing through tissue, a repair construct can becoupled to tissue using other techniques, such as, for example, bywrapping the construct around the tissue.

In an alternative embodiment, a repair construct can be used to pull twoor more tissues into proximity with each other. Any of the repairconstructs provided herein, or derivations thereof, can be used inconjunction with techniques of this nature. As shown in FIG. 14A, arepair construct 710 includes a collapsible snare 746 having a filamentmember 770 that is operable as both a suture pin and a suture shuttle,with two terminal limbs 756, 758 extending from a tubular portion 753. Aterminal portion 779 of the flexible member 770 can be passed through afirst tissue 2003, optionally using a needle or similar tool or devicecoupled to the terminal portion 779 to assist with threading theflexible member 770 through the first tissue 2003, to pull the snare 746and a portion extending distally from the snare 746 through the firsttissue 2003, as shown in FIG. 14B. As also shown in FIG. 14B, theterminal limbs 756, 758 can be passed through a second tissue 2005, alsooptionally using a needle or similar tool or device for each limb 756,758 to assist with threading the limbs 756, 758 through the secondtissue 2005. Once both the snare 746 and the two terminal limbs 756, 758are on a superior side of the tissue 2003, 2005, at least a portion ofthe limbs 756, 758 can be passed through the snare 746, as shown in FIG.14C, and then the snare 746 can be dressed to secure the two pieces oftissue 2003, 2005 together. The limbs 756, 758 can be subsequentlytensioned to pull the two tissues 2003, 2005 closer together. Further,although the embodiment illustrated in FIGS. 14A-14C is directed topulling together two tissues 2003, 2005, a person skilled in the artwould be able to adapt these techniques for three or more tissues bypassing the repair construct, or repair constructs, through additionaltissue that is desired to be involved.

Other methods are provided herein that allow for objects, such astissue, bone fragments, or a variety of other objects, to be fullysecured using a single filament. One example is illustrated in FIGS.15A-15G.

As shown in FIG. 15A, a flexible surgical filament 810 for use in aprocedure can be provided, with the filament 810 including a first end812 having a snare 816 formed therein and a second, leading end 814. Thesnare 816 can be formed in a variety of ways, including using techniquesprovided herein, as well as other known techniques. The leading end 814can likewise have a variety of configurations, including having multiplelimbs as provided in other embodiments of filament repair constructsdisclosed herein, but as shown the leading end 814 is a single limb.

As shown in FIG. 15B, the filament 810 can be positioned substantiallyaround an object 3000, such as tissue or bone fragments, to form a firstloop 811, and the leading end 814 can be folded such that a portionthereof is substantially U-shaped. In other embodiments, the filament810 can be preformed at the leading end 814 to have a substantiallyU-shaped configuration. The leading end 814 can be moved approximatelyin the direction K such that at least a portion of the substantiallyU-shaped leading end 814 passes through the snare 816, as shown in FIG.15C. As a result, a portion of the leading end 814 remains on a firstside of the snare 816 and a second loop 813 is formed by the portion ofthe filament that is within the snare 816, the second loop 813 being onthe other side of the snare 816.

As shown in FIG. 15D, the snare 816 can be collapsed or dressed usingtechniques appropriate for the type of snare that is formed in thefilament 810. Collapsing the snare 816 secures the first and secondloops 811, 813, with the first loop 811 completely surrounding theobject 3000 and the second loop 813 being adjacent to the object 3000.As shown in FIG. 15E, the first loop 811 can then be collapsed aroundthe object 3000 such that the loop 811 engages and holds the object3000. The first loop 811 can be collapsed, for example, by pushing thecollapsed snare 816, which operates as a sliding knot, towards theobject 3000 in the direction L. The collapsed snare 816 can be pushedusing a knot pushing device, by hand, or by other techniques andmechanisms for advancing collapsed snares and sliding knots. Thecollapsed snare 816 can be advanced in the direction L until no furthertension can be provided and thus the filament of the first loop 811 isas fully engaged with the object 3000 as possible.

As shown in FIG. 15F, the leading end 814, starting with a terminal end819 thereof, can be passed through the second loop 813. Once the leadingend 814 is fully through the loop 813, tension can be applied to theleading end 814 in a direction M to collapse the second loop 813, asshown in FIG. 15G. The collapse of the second loop 813 results in a moresecure hold of the object 3000 at least because it locks the previouslycollapsed snare 816 in place and provides additional load-bearingstrength without adding half-hitches. The object 3000 is thus firmly andsecurely grasped by the filament 810 and can be moved and/or used aspart of any number of surgical procedures.

FIGS. 16-22 illustrate a sampling of other procedures that can beperformed in view of the systems and devices disclosed herein. To theextent these figures illustrate a snare, collapsible loop, filaments,and repair constructs, the various types of snares, loops, filaments,and repair constructs provided for herein can be used in conjunctionwith these procedures. Thus, the procedures illustrated are not limitedto being preformed by only the systems and devices illustrated in FIGS.16-22. Further, although in these embodiments the filaments are shows asbeing disposed in tissue, other techniques for associating tissue andfilaments can be used, including wrapping the filaments around thetissue.

FIG. 16 illustrates a filament 910 having a snare 916 and leading end914 like the surgical filament 810 of FIGS. 15A-15G. As shown, thefilament 910 is disposed through two separate tissues 3003, 3005, forinstance by passing the leading end 914 through both tissues 3003, 3005,or by passing the snare 916 through one tissue 3003 and passing theleading end 914 through the other tissue 3005. The leading end 914 canthen be folded into a substantially U-shaped configuration and thefilament 910 can be operated in a manner similar to as described withrespect to FIGS. 15A-15G. Thus, a second loop can be formed bycollapsing the snare 916 around the leading end 914. The collapsed snare916 can be advanced towards the tissue 3003, 3005 to draw the tissue3003, 3005 closer together. Further, the second loop can be advanceddistally by applying tension to the leading end 914, which can assist inmaintaining the location of the collapsed snare 916, and thus the tissue3003, 3005.

FIG. 17 is similar to FIG. 16 except one of the tissues includes ananchor 3008 fixated in bone 3001. Thus, the filament 910′ is passedthrough the tissue 3005 and through a connecting mechanism 3009 of theanchor 3008 in the bone 3001. The connecting mechanism 3009 can be anynumber of components used in bone anchors to allow suture to be coupledthereto, including but not limited to eyelets, posts, and other filamentengagement features. Similar to the embodiment of FIG. 16, a second loopcan be formed by collapsing the snare 916′ around the leading end 914′.The collapsed snare 916′ can be advanced distally to draw the tissue3005 closer to the bone 3001. Further, the second loop can be advanceddistally by applying tension to the leading end 914′, which can assistin maintaining the location of the collapsed snare 916′, and thus thetissue 3005 with respect to the bone 3001.

FIGS. 18 and 19 are similar to FIGS. 16 and 17, respectively, exceptrather than using a single filament 910, 910′, two filaments 1010, 1010′and 1011, 1011′ are used. One filament 1010, 1010′ includes the snare1016, 1016′ and the second filament 1011, 1011′ includes the portion1014, 1014′ previously described as a leading end. As shown, the firstfilament 1010, 1010′ is associated with tissue 3003 (FIG. 18) or ananchor 3008 fixated in bone 3001 (FIG. 19) and a second filament 1011,1011′ is associated with tissue 3005 (FIGS. 18 and 19). The methods arethen performed in a similar manner as described above with respect toFIGS. 16 and 17. Thus, a second loop can be formed by collapsing thesnare 1016, 1016′ around the second filament portion 1014, 1014′. Thecollapsed snare 1016, 1016′ can be advanced distally to draw the tissue3005 closer to tissue 3003 or the bone 3001. Further, the second loopcan be advanced distally by applying tension to the portion 1014, 1014′,which can assist in maintaining the location of the respectivecomponents 3001, 3003, 3005, and 3008 coupled to the filaments 1010,1010′ and 1011, 1011′.

FIG. 20 illustrates another embodiment in which two filaments 1110, 1111are used to draw tissue 3005 closer to an anchor 3008 disposed in bone3001. The operation of this construct can be similar to those describedabove with respect to FIGS. 15A-19. As shown, a first filament 1110having a snare 1116 and a terminal end 1115 is coupled to an anchor 3008fixated in bone 3001. The anchor 3008 can include a one-way slidingmechanism 3009 to allow the terminal end 1115 to be used as a tensioningtail to collapse the snare 1116. The second filament 1111 can be coupledto the tissue 3005, the second filament 1111 having a leading end 1114that can be folded to have a substantially U-shaped configuration. Theleading end 1114 can be disposed in the snare 1116 and the snare can becollapsed to form a second loop. The collapsed snare 1116 can beadvanced distally to draw the tissue 3005 towards the bone 3001, forinstance by applying tension to the terminal end 1115. Further, thesecond loop can be advanced distally by applying tension to the leadingend 1114, which can assist in maintaining the location of the tissue3005 with respect to the bone 3001. Final tensioning can be carried outby applying tension to the terminal end 1115.

FIGS. 21-22 illustrate yet two further embodiments of constructs for usefor drawing tissue to bone, the operation of which can be similar tothose described above with respect to FIGS. 15A-20. FIG. 21 includes afirst filament 1210 having a first end 1212 configured to couple to arepair construct 1310 and a second leading end 1214, with the first end1212 being coupled to an anchor 3008 disposed in bone 3001 and thesecond end 1214 being disposed through tissue 3005. A second filamentforms a repair construct 1310 having a collapsible loop 1320, a snare1346, and a connecting neck 1350 disposed therebetween. The loop 1320includes a sliding knot 1326 and has a collapsible tail 1330 operable tocollapse the loop 1320 by moving the knot 1326 distally toward theanchor 3008. Similar to other embodiments described herein, thecollapsible tail 1330 can advance the sliding knot 1326 in aratchet-like or incremental fashion. The leading end 1214 can be foldedto have a substantially U-shaped portion, which can be passed throughthe snare 1346. The snare 1346 can be collapsed around the leading end1214 to form a second loop. The sliding knot 1326 can be advanceddistally, for instance by tensioning the tail 1330 in a direction N,thereby drawing the tissue 3005 toward the bone 3001. Further, thesecond loop can be advanced distally by applying tension to the leadingend 1214, which can assist in maintaining the location of the slidingknot 1326, and thus the tissue 3005 with respect to the bone 3001. Finaltensioning can be carried out by applying tension to the collapsibletail 1330.

The method illustrated in FIG. 22 is similarly operated as the methoddescribed with respect to FIG. 21, but the collapsible loop 1320′ of therepair construct 1310′ is coupled directly to the anchor 3008. Once afirst filament 1210′ is coupled to the repair construct 1310′ bycollapsing the snare 1346′ around the leading end 1214′ of the firstfilament 1210′ disposed therein, collapsing the loop 1320′ draws thetissue 3005 towards the bone 3001 in which the anchor is disposed.

The methods of FIGS. 21 and 22 could also be used in conjunction withmultiple tissues and no anchors and bone, and any of the methods ofFIGS. 16-22 can be used with any number of components being drawntogether, such as anchors, bone, and tissue, including more than twocomponents, as well as any number of filament construct combinationswithout departing from the spirit of the present disclosure.

One skilled in the art will appreciate further features and advantagesof the invention based on the above-described embodiments. Accordingly,the invention is not to be limited by what has been particularly shownand described, except as indicated by the appended claims. Further,although the systems, devices, and methods provided for herein aregenerally directed to surgical techniques, at least some of the systems,devices, and methods can be used in applications outside of the surgicalfield. By way of non-limiting example, the methods of grasping objectsdescribed with respect to FIGS. 15A-15G can be used in contexts outsideof surgical procedures and outside of the medical field. Allpublications and references cited herein are expressly incorporatedherein by reference in their entirety.

What is claimed is:
 1. A surgical method, comprising: selecting aflexible surgical filament having a snare at a first end thereof and anopposed leading end; positioning the surgical filament substantiallyaround an object to form a first loop; passing the leading end of thefilament through the snare such that the leading end remains on one sideof the snare and a second loop formed by the portion of the filamentwithin the snare is on another side of the snare; collapsing the snarearound the filament disposed therein to secure the first and secondloops, the first loop completely surrounding the object and the secondloop being adjacent to the object; collapsing the first loop around theobject to engage the object with the filament; passing the leading endof the filament through the second loop; and collapsing the second looparound the filament to secure the filament to the object.
 2. The methodof claim 1, wherein collapsing the first loop around the object furthercomprises pushing the collapsed snare towards the object.
 3. The methodof claim 1, wherein collapsing the second loop around the filamentfurther comprises tensioning the leading end of the filament.